In Review

Clinical Implications of Research on Religion,

Spirituality, and Mental Health

Marilyn Baetz, MD, FRCPC1; John Toews, MD, FRCPC2

The relation between religion and (or) spirituality (RS), and mental health has shown
generally positive associations; however, it is a complex and often emotion-laden field of
study. We attempt to examine potential mechanisms that have been proposed as mediators
for the RS and mental health relation. We also examine more philosophical areas including
patient and physician opinions about inclusion of RS in patient care, and ethical issues that
may arise. We review suggested guidelines for sensitive patient inquiry, and opportunities
and challenges for education of psychiatrists and trainees. We also study practical ways to
incorporate psychospiritual interventions into patient treatment, with specific reference to
more common spiritual issues such as forgiveness, gratitude, and altruism.
Can J Psychiatry. 2009;54(5):292–301.

Clinical Implications
· RS may impact mental health through multiple dimensions including the biological,
psychological, and social realms.
· Mental illness is a time when personal resources are challenged and RS may be a clinically
significant positive or negative source of coping.
· Education about RS and mental health will inform clinicians about ways of inquiry, potential
issues to address, and ethics of the interaction.

Limitations
· There is limited research into practical psychospiritual interventions in psychiatrically ill
populations.
· The research has just begun to examine the complexity of proposed mechanisms from a
multidimensional perspective.
· Measures of RS are often assessed in ways that may blur differences that exist between faith
traditions.

Key Words: religion, spirituality, mechanisms, ethics, education, clinical implications

n general, research has shown RS positively affects mental
I health outcomes, as noted by Koenig.1 Although largely
reporting on US studies, an increasing body of literature on
the effects of spirituality on mental health from numerous
countries, including Canada,2–6 indicates the findings apply
across boundaries and religions.
However, the literature is dominated by a spirituality that
finds its expression through religious observance. From a
practical perspective, this raises the question of the clinical
relevance of these findings for people who are not necessarily
religiously observant. The relevance could be demonstrated
by an exploration of the putative mechanisms through which
spirituality may exert its affect. This perspective is important
for a population such as Canada’s, where, during the last
decades, the percentage of Canadians who report regular
church attendance has decreased dramatically.7 Fifty years
ago, Canada had a larger proportion of its population attend-
ing religious services than the United States; this proportion
has since noticeably dropped, positioning Canada about half-
way between the United States and European countries.7

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Two major trends are apparent. First, a smaller percentage of
Canadians attended religious services at least monthly in
2004, compared with 1985 (32% and 41%, respectively).8
Second, according to 2001 census data,9 the proportion of the
population identifying with a religion other than Christianity
is increasing, largely owing to immigration, while the propor-
tion of the population classified as Catholic or Protestant
decreased from the previous decade. Statistics of religious
affiliation alone do not tell the whole story. Bibby’s research10
on the sociology of religion in Canada suggests a modest
upswing in the number of people adhering to some of the faith
communities, while the number of nominally religiously
adherent people is decreasing. Further, while a person may
not affiliate with a faith community, they may still identify
with a church for certain religious rituals (for example, wed-
dings and funerals).
Canada’s policy of multiculturalism (diversity) may possibly
contribute to the increase in the number of people who iden-
tify themselves as spiritual but not religious. It is
quintessentially Canadian to search for common ground and
therefore to seek what disparate ethnic or religious groups
may have in common, thus emphasizing a spirituality that is
not bound specifically to a particular religion.
Given the importance of this discussion for a broader context
than religious observance and practice, and in light of the
review examining research in mental health,1 this paper will
focus on the clinical implications of this research to the psy-
chiatrist and patient.
Mechanisms Mediating Outcomes of RS
Practice in Mental Health
Research considering religion, spirituality, and health (physi-
cal or mental) comes from diverse fields including cognitive
and social psychology, neuroscience, epidemiology, and
medicine. This has led to widely varying models of religion’s
influence on health—health behaviours, social support, psy-
chological states, superempirical or psi states11—reflecting
that the different pathways by which RS may influence health
are likely multilevelled.12 Mechanisms working at one level
(for example, the psychological) do not preclude mechanisms
working at other levels (for example, the biological or
social),13 leading some to conclude that the power of spiritual-
ity may lie in the fact that it is “fully embedded in the fabric of
Abbreviations used in this article
MDD major depressive disorder
PFC prefrontal cortex
PTSD posttraumatic stress disorder
RS religion and (or) spirituality
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Clinical Implications of Research on Religion, Spirituality, and Mental Health
life.”14, p 21 The challenge for research has been to move from
simply describing a relation to exploring factors that may
underlie this association.
Social
The social domain was one of the first areas explored for
mediators of the religion–health association. In this domain,
environmental influences such as health behaviours, group
connectedness, and social resources have been primarily
studied as mechanisms through which religion may influence
health and (or) mental health.15–18 Examples of religion-
based influences on health behaviours include proscriptions
regarding the excess use of nicotine, alcohol, or drugs of
abuse, and in some cases prescriptions about diet. Substance
dependence and abuse have high comorbidity with many
psychiatric disorders but correlate negatively with RS mea-
sures,2,19 particularly in the context of a supportive and nur-
turing belief system.20 Religious service attendance is
positively associated with other positive health behaviours
including use of preventive health care, enhanced physical
activity, and fewer risk-taking activities21,22; the relation with
obesity remains uncertain, with some studies indicating obe-
sity is positively associated with religiosity.23
Social support is another plausible mechanism by which reli-
gion may affect mental health. Some components of reli-
giousness, such as religious service attendance and religious
coping, have been linked cross-sectionally and longitudi-
nally to lower depressive symptoms as well as higher social
support.24 However, data concerning social support as a
mediator in this religion–depression relation are not conclu-
sive,15,25,26 and thus religiousness may influence depression
through additional pathways.27 Social support may indirectly
mediate this relation along with other forms of psychological
and social activity, such as optimism and volunteering.28
Teasing apart positive and negative church-based social
interactions has also demonstrated differential and signifi-
cant effects on depressive symptoms.29 Positive interactions
are associated with fewer depressive symptoms and negative
interactions are associated with higher levels of depressive
symptoms.
Psychological
Allport and Ross30 first attempted to discriminate among peo-
ple according to their cognitive religious content and the
degree to which religious values were applied to their lives.
They proposed the concept of extrinsic and intrinsic religious
orientation. People with an extrinsic orientation are disposed
to use religion for their own ends (that is, security, solace,
sociability, distraction, status, and self-justification). People
with an intrinsic orientation find their reason for being in
their religious beliefs.31 A meta-analytical review of reli-
giousness and depression demonstrates a clear contrast
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where intrinsic religious motivation is associated with lower
depression and extrinsic religion motivation with higher
depression.32
In a review of cognitive-behavioural mechanisms that may
underlie the association between RS and mental health, James
and Wells33 propose that religious beliefs (schema) provide a
mental model for guiding appraisal of life events and are
important in self-regulation of thinking processes. They note
religious attributions for life events may provide a sense of
meaning, perceived control, and predictability, particularly in
times of high stress. This sense of meaning may help to
reframe trials as a spiritual opportunity, a wake-up call, or
even punishment.34,35 Interestingly, the strength of one’s
belief position (whether it be no faith or strongly religious)
may be an important indicator of lower distress, compared
with a weaker belief system (that is, extrinsic religiousness)
that may not be able to respond to the types of questions raised
by significant stressors. Religious behaviours that contribute
to self-regulation by reducing self-focus and worry while pro-
viding a calming effect (for example, contemplative prayer,
mindfulness meditation, and religious rites) are positively
associated with mental health.33,36 Religiously motivated
behaviours that increase self-focus and worry are associated
with intrusive thoughts, thought control and undoing, and
poorer mental health.37,38
Understanding the role of RS in coping with mental health
issues is also a significant field of psychological study. As a
leader in this field, Pargament39 has developed positive and
negative religious coping measures that reflect various coping
styles, such as self-directing, collaborative, deferring, and
surrender. He summarizes the findings in this body of
research by noting that better mental health has been linked
positively to a religion that is internalized, intrinsically moti-
vated, and based on a secure relationship with God and nega-
tively to a religion that is imposed, unexamined, and reflective
of a tenuous relationship with God and the world.35 This state-
ment underscores the complexity of RS coping, which
includes spiritual appraisal, personal factors (religious doc-
trine, orientation, and hope), behaviours (religious service
attendance and private RS practices), and spiritual connec-
tions (nature, others, and transcendent other).34 The degree to
which this type of coping or cognitive schema promotes posi-
tive emotions, such as forgiveness, gratitude, optimism,40
compassion,41 or hope, and how these pathways may impact
mental health42–44 are reviewed in a later section.
Biological
An emerging field known as neurotheology explores the rela-
tion between spirituality, spiritual experiences, and neurolog-
ical processes.45 In classic neuroimaging studies (single
photon emission computerized tomography) of Buddhist
294
monks and Franciscan nuns meditating or in prayer,
Newberg et al46 show increased blood flow in the frontal
lobes (possibly representing increased focus), cingulate gyri,
and thalami, and decreased blood flow in the superior parietal
cortices (possibly representing loss of physical representa-
tion of self).12 Muramoto47 hypothesizes religious activity is
particularly localized in the PFC, which is involved with
error detection, monitoring, and compliance with social
norms. A healthily functioning PFC would be represented by
compliance to norms, empathy, and compassion; a
hyperfunctioning PFC would be characterized by rigid con-
formity and perhaps a delusional interpretation of God’s
mind; a hypofunctioning PFC would imply reckless lack of
self-control and apathy. However, this field of study is not
without detractors. Sloan48 has questioned the value of this
research as it either implies something special in the religious
experience, owing to its neurophysiological underpinnings,
or it simply shows areas of the brain that are active in a partic-
ular activity, neither of which he feels advance the under-
standing of the field in a meaningful way.
Physiological variables such as neurohormonal,
neuroimmunologic, or cardiovascular functioning are also
explored as potential mediators. In a computer task–induced
stressor, religiosity was associated with lower cortisol reac-
tivity in undergraduate students and in males with lower
blood pressure.49 In HIV-positive men and women, spiritual-
ity was associated with higher positive reappraisal coping
scores and greater benefit finding, which were in turn both
related to lower depressive symptoms. Spirituality was also
related to lower urinary cortisol through positive benefit
finding.50
This possible attenuation of the stress response has signifi-
cant implications for both physical and mental health. Asso-
ciations between religious activities and lower blood
pressure51 as well as better immune functioning52 are also
reported. In contrast, no association was found between RS
(Taoist and Buddhist) and biological markers (interleukin-6,
blood pressure, and urinary cortisol) after controlling for
health status in a large sample of elderly Taiwanese people;
the study53 concluded that social participation had a more
robust effect. Differentiating what is truly an RS intervention
or effect from a more general social response remains a chal-
lenge in measurement and a focus of criticism of this line of
research.
A more comprehensive measure of overall physiological
state may provide even further useful information in under-
standing the role RS may play in mental and physical
health.54 Physiological biomarkers capture dysregulation in
the cardiovascular system, hypothalamo–pituitary–adrenal
axis, sympathetic system, and metabolic processes, and refer
to the body’s stress response. Stress promotes adaptation in
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body systems in the short term but prolonged stress leads, over
time, to wear and tear on the body. This condition, or allostatic
load,55 leads to impaired immunity, atherosclerosis, obesity,
and atrophy of nerve cells in the brain. Many of these pro-
cesses are seen in psychiatric disorders.56,57 Spiritual, reli-
gious, and other factors that enhance coping, decrease
physical or emotional stress, decrease risk-taking behaviours,
or enhance positive health behaviours may be protective fac-
tors against the chronic wear and tear on the body systems.58
Cognitive factors such as a sense of coherence59 or other fac-
tors such as social relationships60 are protective regarding
allostatic load and may be associated with religious activity.61
Maselko et al54 analyzed data from the McArthur Study of
Aging to determine the relation between allostatic load and
religious service attendance, and any mediative effect of
social networks. While no effect was found for males,
allostatic load was significantly lower for females, with high
worship frequency independent of social networks.
Genetic
Genetic studies have begun to inform the RS and mental
health field. Kendler et al62 found a strong environmental role
for similar familial RS beliefs and practices but also found
genetic factors accounted for 29% of the variance of personal
devotion (a composite of salience of religious beliefs, church
attendance, private prayer, and seeking spiritual comfort).
Personal devotion was also an important factor in lowering
the risk for substance use and dependence, and protected
against the depressogenic effects of major personal
stressors.63 Analysis of the Dutch Twin Registry found differ-
ent aspects of religion were entirely explained by environ-
mental factors with the exception of the personality factor
disinhibition. Receiving a religious upbringing seemed to
reduce the influence of genetic factors on disinhibition, par-
ticularly in males64; however, similar to a study from the
Virginia Twin Registry,65 very little contribution to other
personality traits was noted.
Practical Implications
Given the burgeoning research in the area of the biological
and psychological mechanisms relating to the health benefits
of RS, we now turn our attention to the practical implications
of the relation between RS and mental health. We will attempt
to answer the question of whether any empirically based
approaches are open to patients who wish help of a spiritual
nature. In including these topics in our review, we make no
claim that these emotions or states are the sole purview of
either religion or spirituality. They are included because they
are teachings held in common by major religions and many
other spiritual systems as one of the outcomes of spiritual
practice.
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Clinical Implications of Research on Religion, Spirituality, and Mental Health
During the past 2 decades, researchers have discovered that
positive acts and emotions have a profound effect on health.
Funding became available for research in positive psychol-
ogy, both from conventional grantors and from institutes
such as the Templeton-funded Institute for Research on
Unlimited Love. Consequently, research has been under-
taken in fields such as altruistic love, forgiveness, and
gratitude—all traits found in both religious and spiritual
teachings. Below, we address selected research on these
psychospiritual states but note much has been undertaken by
academic psychologists and may not be immediately
applicable to practice.
Altruism
Altruistic behaviour is defined as the degree of obligation felt
in situations involving helping others at one’s personal
expense.66 In a large, stratified, random sample (n = 2016) of
members of the Presbyterian Church throughout the United
States, giving help was associated with better mental health,
compared with receiving help.67 This is consistent with the
benefits of self-initiated volunteerism on mental health.68 In
adolescence, generative behaviour—of which altruism is a
major component—can predict being peaceful, happy, calm,
and in better health in old age.69 Altruistic behaviour in older
age augments well-being and life satisfaction.70
There is a limit to the amount of time that can be spent in vol-
unteer altruistic activities, and exceeding this limit can
adversely impact health.67 While evidence indicates helping
others promotes mental health, almost no research explores
the effects of altruistic behaviour on mental disorders. We
found only one paper71 examining the role of altruistic behav-
iour in generalized anxiety disorder and MDD in a broadly
defined middle-aged population (aged 25 to 74 years), part of
the National Survey of Midlife Development in the United
States. This study noted a small beneficial effect of altruistic
behaviour on subjects with anxiety disorders and a signifi-
cant negative effect in patients with MDD. Notably, this
cross-sectional study measured altruism by responses to
hypothetical questions and not to actual behaviours.
Gratitude
The grateful disposition has been demonstrated to be a dis-
crete emotional experience and an affective trait that can be
differentiated in 3 distinct domains: emotionality–
well-being, pro-social behaviour, and spirituality–
religiousness.72 Further, gratitude is inversely related to
neuroticism.73 Grateful moods are generated by influences of
the more stable personality traits, and also from experienced
daily events.73 Some people are evidently more prone to be
grateful, while others respond more to the events of the day;
both contribute to mood.
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Focusing on gratitude can improve well-being even in people
who are chronically ill. Social psychology studies have dem-
onstrated being dominated by negative emotions as a reaction
to an acute stressor is a temporary state. We adapt, and our nat-
ural traits gradually assert themselves, and moods of happi-
ness and gratitude can become apparent.74 Gratitude improves
one’s sense of well-being; significant increases in positive
affect, life satisfaction, and subjective well-being were noted
in subjects (both in students and in neuromuscular patients)
who kept a gratitude diary each day, compared with those who
reported their irritations.75 We did not locate any studies repli-
cating these findings in people suffering from psychiatric
illnesses such as depression or anxiety.
Forgiveness
Many definitions of forgiveness exist but all seem to agree it is
a positive method of coping with an offence that causes the
victim to deal with the negative emotions, thoughts, and
actions directed at the offender.76 Therefore, forgiveness is a
reduction in unforgiveness and the promotion of more posi-
tive understanding and regard for the offender. This definition
of forgiveness does not: include expectations of releasing the
offender from responsibility, ignore or minimize the offence,
and demand reconciliation.
Unforgiveness has been associated with negative emotional
and physical effects. Unforgiving thoughts engender more
adverse emotions indicative of stress as measured by
electromyelogram of the corrugator muscle, skin conductance
levels, heart rate, and mean arterial pressures, as compared
with a forgiving response group77; we postulate these emo-
tional and physiological responses experienced chronically
represent a stress that can affect the functioning of the immune
system. Chronic stressors, including the stress of mental ill-
nesses, are part of the burden of stress leading to health conse-
quences.78 For example, chronic hostility in couples is
associated with differences in wound healing and inflamma-
tory cytokine production, compared with couples with more
positive interactions.79
Numerous studies indicate the positive effect of forgiveness
on self-rated health,43 hypertension,80 chronic pain,81,82 addic-
tions,83 and PTSD.84 Data from the Truth and Reconciliation
Commission in South Africa85 indicate depression, PTSD,
and other psychiatric disorders are significantly higher among
people who demonstrate less forgiveness years after the
events.
Various psychoeducational and psychotherapeutic forgive-
ness interventions have been developed and evaluated, and
are summarized in 3 recent reviews.76,86,87 A meta-analysis by
Baskin and Enright86 of 9 forgiveness outcome studies found
them grouped into 3 separate models. The first model was
based in individual therapy and the second model focused on
296
the process of forgiveness in groups; the time commitment
for both models was considerable. The third grouping was a
brief, decision-to-forgive–based model. The findings indi-
cate process-based forgiveness therapy was more effective
than decision-based therapy, individual counselling was
more effective than group-based counselling, and the process
model in particular proved to be effective. Therapies of lon-
ger duration were found to be more effective, in keeping with
the process model.
Wade and Worthington76 analyzed 14 studies for the com-
mon core of forgiveness interventions. Most of the
approaches spent time defining forgiveness, recalling the
hurt, then emphasized building empathy for the offender as
part of common humanity. These studies also helped people
engage in the delicate task of acknowledging their own
offences. People are helped to commit to forgiveness, recog-
nizing the necessity to reduce unforgiveness, either through
discussion or cognitive reframing.
In a more recent study, Harris et al88 devised a 6-week
group-based forgiveness training program using a combina-
tion of psychoeducation, cognitive restructuring, positive
and negative visualizations, and heart-focused meditation
techniques. The randomized control study (n = 259, enrolled;
n = 134, in treatment group) focused on event-specific for-
giveness, forgiveness likelihood in new situations, and
psychosocial outcomes related to health, with ratings
obtained at 6 weeks and 4 months. The program was 2 to 3
times more effective in reducing negative thoughts about the
target transgression than the control group, and produced sig-
nificant increases in positive thoughts, forgiveness self-
efficacy, and forgiveness in new situations. Significant
decreases in anger and stress were also noted. In short, for-
giveness interventions seem to be useful therapeutic
approaches for people requiring a forgiveness focus.
Psychiatrist–Patient Opinions Regarding RS
in Clinical Practice
A 1986 systematic review of religious variables in 4 major
psychiatric journals highlighted the paucity of research in RS
and mental health.89 At that time, articles appeared highlight-
ing the disproportionate examples of religion to describe
psychopathology in the Diagnostic and Statistical Manual of
Mental Disorders, Third Edition, Revised90 that patients fre-
quently turned to religious professionals for mental health
care,91 and that there were higher levels of religious beliefs
among patients than among psychiatrists.92 Religion became
termed “the forgotten factor”93, p 1 in mental health. Twenty
years later, and after a vast amount of research in RS and
mental health, surveys still show psychiatrists remain less
religious than other physicians,94 their patients, and the gen-
eral population. Notably, psychiatric95,96 and medical
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patients97–99 still express an interest in having their spiritual
needs considered. Although a shift is evident, as recent
Canadian95 and US100 surveys indicate most psychiatrists now
appreciate the importance of RS in mental health and appear
more comfortable in discussing it with patients. The physi-
cian’s own RS beliefs continue to remain the most important
predictor of attitude and comfort with the topic.101 The aware-
ness of psychiatrists about the research in RS and mental
health is not known, although various psychiatric organiza-
tions, worldwide, are including sections on religious and spir-
itual interests (for example, the World Psychiatric
Association; the Royal College of Psychiatrists, United
Kingdom; the Center for Spirituality, Theology and Health,
Duke University, United States; and, the Association of
Spirituality and Mental Health, Canada.)
Psychiatric Education Dealing With RS Issues
The interest in the interface between RS and psychiatry has
resulted in initiatives to include the topic in psychiatric educa-
tion.102,103 Reasons to integrate RS in psychiatric training are
numerous. Patients consistently express the preference for
consideration of RS issues in their care.99,104,105 A survey of
Canadian psychiatric patients indicates 53% would welcome
inquiry about RS in their mental health care.95 Patient-centred,
whole-person care is desired by patients for whom spirituality
is a part of their care.95 In addition, the large body of empirical
research on RS and mental health is an important addition to
overall learning. Accreditation standards for medical schools,
as defined by the Liaison Committee on Medical Education in
conjunction with the Committee on Accreditation of
Canadian Medical Schools,107 and for postgraduate programs,
through the Royal College of Physicians and Surgeons of
Canada (Canadian Medical Educational Directions for Spe-
cialists),108 now require competency in understanding ways in
“which people of diverse cultures and belief systems perceive
health and illness and respond to various symptoms, diseases,
and treatments.”107, p 9
The focus is on being able to communicate effectively, includ-
ing dialogue about religious and spiritual values, understand-
ing one’s personal perspective during treatment, and being
able to demonstrate ethical human values in understanding the
patient’s cultural and spiritual context. The John Templeton
Foundation in conjunction with the George Washington Insti-
tute for Spirituality and Health has facilitated the educational
component through awards to undergraduate and postgradu-
ate Family Medicine and Psychiatry programs for curriculum
design and implementation. This initiative has helped to
spearhead the development of many programs in the United
States. A survey of Canadian psychiatry programs found resi-
dents were receiving only minimal exposure to the interface of
RS and psychiatry.109
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Clinical Implications of Research on Religion, Spirituality, and Mental Health
Model curricula have been described,102,110 including one
specific to Canada.109,111 Time involvement ranges from
many hours of teaching to short workshops, but generally
includes the objectives of learning a short, respectful, and
nonjudgmental spiritual needs assessment, familiarizing
with spiritual care resources, and being able to justify the
inclusion of spirituality by reference to current, credible
research on spirituality and mental health.
Addressing Spirituality in Psychiatric Care
As research into the relation between RS and health has
expanded, physicians are left to determine the ramifications
(if any) to the patient encounter. Family medicine, palliative
care, oncology, and internal medicine have developed princi-
ples for accommodating RS beliefs and recommendations for
discussion.112–114 Short spiritual interviews, with acronyms
designed to aid memory, have been suggested as part of the
social history, such as FICA (Do you have a Faith or belief?,
Importance in clinical care, Are you part of a faith Commu-
nity?, Is there some way you would like it to be Addressed as
part of care?113) and HOPE (source of Hope or meaning,
Organized religion, Personal spirituality or Practices, and
Effect on medical care and [or] End of life115). The same
approaches have been encouraged within psychiatry116; how-
ever, caution is required depending on the degree of patient
distress and psychopathology that may preclude this and
often other types of inquiry.117
Psychotic phenomena may have a religious orientation,
including delusions or distortions of normative religious
beliefs, such as scrupulosity, delusions of specific deity guid-
ance, or indeed being a deity.117 People with depression may
have ruminations of past transgressions and lose their sense
of connection with their higher power or feel eternally
damned.118 This does not suggest all people with serious
mental illness will express these forms of pathology, and sen-
sitive inquiry in more stable people may reveal spiritual
issues that hinder or help diagnosis or treatment. In a survey
in Geneva of patients (n = 100) with a psychotic illness, only
16% had overlap between religious beliefs and psycho-
pathology; however, others expressed a conflict between
their religious beliefs and medication of which their psychia-
trist was unaware.119 In a survey of more than 400 people
with persistent mental illness in Los Angeles County, 48%
indicated religion became more important to them when their
symptoms worsened. Further, these 48% were less likely to
be admitted to hospital in the year prior than those for whom
RS became less important when symptoms worsened.120
Therapy groups on spiritual issues for patients with chronic
and severe mental illness, conducted with careful attention to
group rules, have been shown to be successful ways to
explore how spirituality is affected by mental illness.121,122
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Acknowledging the patients’ explanatory framework for their
illness, expanding the consultative network, and being aware
of spiritual interventions may be outcomes of open spiritual
inquiry.123 Guidelines for evaluating if medical goals are
being achieved and if the patient’s values are preserved help to
inform the clinician about spiritual interventions that may be
sought by the patient.124
Ethics
Research into the relation between spirituality and health
raises ethical questions about the use of RS in clinical settings.
Opinions on this issue range from support for an open promo-
tion of religious observance, if it is of benefit, to statements
that a person’s spirituality is private and certainly not within
the scope of health care practice except by chaplains as mem-
bers of health care teams. The point is made that a health pro-
fessional’s personal RS belief system is not qualification
enough to address this topic with patients. Sloan et al125 argue
the existence of 4 major areas of ethical concern. First, owing
to the power differential between a physician and patient, an
element of coercion can be present in matters of faith.126 Sec-
ond, they argue a person’s faith or spiritual practice is inher-
ently private and need not be revealed to a health care
professional. Further, occasions may occur where harm could
come from the specific religious approach; for example, pro-
motion of the belief that if one just has enough faith, their dif-
ficulties would resolve. Finally, they argue that, in effect,
advice to engage in religious observances is inherently dis-
criminatory, as the health benefits apply only to those who
believe.48,126
The counter to this position is that medicine is not restricted
purely to a materialistic perspective. Instead, it encompasses
the biopsychosocial–spiritual model. Further, research shows
many patients want to be asked about their spiritual commit-
ments and concerns. This is important information for the
physician and the health care system, and consequently RS
influences should be acknowledged and incorporated into a
more meaningful relationship with the patient.126–128 As a gen-
eral rule, most research stops short of advocating increased
religious observance by the patient for potential health
benefits. Considering an interdisciplinary approach to spiri-
tual issues that arise in mental health care is prudent, and refer-
ral to the chaplain who is the spiritual care expert is
recommended.129
A high percentage of the population acknowledges they pray,
and indeed a recent meta-analysis shows at least equivocal
evidence of the effectiveness of nonlocal prayer.130 What then
are the ethical considerations of whether a physician prays
with their patients? Again, opinions range from supporting
the occasional participation of a physician or health care team
member in prayer at the patient’s request or as a silent witness
298
to the patient’s prayer, to deferring instead to a chaplain with
training in the application of spiritual practices within the
health care system. Post et al128 summarize a well-reasoned
position:
Physician[-]led prayer is acceptable only when
pastoral care is not readily available, when the
patient is intent on prayer with the physicians, and
when the physician can pray without having to feign
faith and without manipulating the patient.p 582
Summary and Conclusions
There has been much research and discussion about potential
mechanisms by which RS may impact mental health, sug-
gested clinical implications and applications, along with cau-
tions and concerns. The diversity of research and the various
fields of study underscore the complexity of attempting to
understand how a person’s faith and beliefs relate to their ill-
ness or health. The challenge for the clinician is to synthesize
this research from different orientations (that is, cognitive,
social, and biological) to make it applicable to patient care.
First, being aware of this dimension of a person’s life is a key
factor, and practical tools for sensitive inquiry have been
reviewed. Second, it is important that the psychiatrist recog-
nizes that times of mental illness are times that challenge cop-
ing resources and RS may be a positive or a negative factor in
coping. For this reason, RS may benefit from meaning explo-
ration with each person. Third, interventions that have exam-
ined volunteering, gratitude, and forgiveness show
promising results in healthier populations and the evidence
suggests they may be at least cautiously explored in
psychiatric populations. This would be a potential area for
future research.
Enhancing physicians’ awareness of the literature and pro-
viding the groundwork to consider a balanced approach to
RS in mental health is important in this potentially emotion-
ally charged and polarizing field. Providing sensitive,
patient-centred care involves the challenge of considering all
aspects of our patients’ lives, being willing to examine and
understand our own biases, and working together to optimize
mental health. Open dialogue, empirical research, and scru-
tiny by peer review remains of utmost importance.
Funding and Support
The Canadian Association of Psychiatry proudly supports the In
Review series by providing an honorarium to the authors.
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Manuscript received and accepted October 2008.
1
Associate Professor of Psychiatry, University of Saskatchewan,
Saskatoon, Saskatchewan.
2
Professor of Psychiatry, University of Calgary, Calgary, Alberta.
Address for correspondence: Dr M Baetz, Department of Psychiatry,
University of Saskatchewan, Saskatoon, SK S7N 0W8;
m.baetz@usask.ca

Résumé : Implications cliniques de la recherche sur la religion, la spiritualité et la

santé mentale
La relation entre la religion et (ou) spiritualité (RS), et la santé mentale a montré des associations
généralement positives; toutefois, il s’agit d’un domaine d’étude complexe et souvent chargé
d’émotions. Nous tentons d’examiner les mécanismes potentiels qui ont été proposés comme
médiateurs de la relation entre la RS et la santé mentale. Nous examinons également des domaines
plus philosophiques, notamment les opinions des patients et des médecins sur l’inclusion de la RS
dans le soin des patients, et les questions d’éthique qui peuvent être soulevées. Nous examinons les
lignes directrices suggérées pour les renseignements délicats sur les patients, ainsi que les
possibilités et les défis de la formation des psychiatres et résidents. Nous étudions aussi des moyens
pratiques d’incorporer des interventions psychospirituelles dans le traitement des patients, en faisant
référence spécifiquement à des notions spirituelles plus répandues comme le pardon, la gratitude et
l’altruisme.

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